Perceived neighborhood disorder, social cohesion, and depressive symptoms in spousal caregivers

Abstract Objectives Prior research into the factors linked to mental health of caregivers of older adults have largely focused on individual- or household-level characteristics, but neighborhood supports and stressors may also matter for caregiver mental health. The current study fills this knowledge gap by examining the association of neighborhood social cohesion and disorder and depressive symptoms among spousal caregivers. Method We used data from the 2006 to 2016 waves of the Health and Retirement Study, which include 2,322 spousal caregivers. Negative binomial regression models were estimated to examine the association of perceived neighborhood social cohesion and disorder with depressive symptoms. Results A higher level of perceived neighborhood social cohesion was associated with fewer depressive symptoms (b = –0.06, 95% CI: −0.10, −0.02). On the other hand, greater perceived neighborhood disorder was associated with more symptoms (b = 0.04, 95% CI: 0.01, 0.08). The association of perceived social cohesion with depressive symptoms remained even after controlling for perceived disorder, but neighborhood disorder was no longer associated with depressive symptoms after accounting for reported neighborhood social cohesion. Conclusions This study suggests neighborhood supports and stressors matter for caregiver well-being. Neighborhood-based social support may be particularly important for caregivers as they navigate the challenges caregiving for an aging spouse can bring. Future studies should determine if enhancing positive characteristics of the neighborhood promotes well-being of spousal caregivers.


Introduction
Family members are the primary source of care and support for community-dwelling older adults experiencing challenges in health and functioning.Each year, at least 17.7 million Americans provided assistance to their older family members who need help because of a limitation in their physical, mental, or cognitive functioning (Schulz & Eden, 2016).With the prevalence of chronic conditions among the older population and an increase in disabled life expectancy (Crimmins et al., 2016;Robert Wood Johnson Foundation, 2010), the need for caregiving is growing and the number of caregivers is projected to increase accordingly.Given the increasing number of caregivers, it is important to consider issues related to their health and well-being.
Caregiver mental health is one of the important issues that needs to be addressed.Efforts have been made to identify factors affecting caregivers' mental health.However, existing literature on caregiver mental health has mainly focused on individual-or household-level factors, such as caregiving intensity, spousal relationship quality, and proximity to children (e.g., Kim et al., 2017;Meyer et al., 2021), neighborhood factors have yet to be examined despite the growing evidence that supports the importance of neighborhood context in mental health (e.g., Barnett et al., 2018;Cho, 2022;Hill & Maimon, 2013).The purpose of the current study is to understand how neighborhood social environment may contribute to caregiver mental health.

Caregiving and mental health
Caregiving has been described as a stressful experience, which erodes caregivers' mental health (Pinquart & Sörensen, 2003;Schulz & Sherwood, 2008).Previous studies have reported that caregivers tend to experience higher levels of stress and anxiety, more depressive symptoms, and lower subjective well-being than non-caregivers (Hajek & König, 2016;Lavela & Ather, 2010;Pinquart & Sörensen, 2003).Caregivers providing high intensity care are even at a greater risk for poor health outcomes.For instance, providing care to spouses with high levels of disability and higher levels of emotional and physical strain as a result of providing care encouraged health-risk behaviors (e.g., eating less, not having enough time to exercise, not getting enough rest, forgetting to take medications, delaying or missing doctor's appointments) and increased risk for poor health, anxiety, and depression symptoms (Beach et al., 2000;Kim et al., 2017).
Spouses are one of the main groups providing assistance in completing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) to their spouses (AARP and National Alliance for Caregiving, 2020; Schulz & Eden, 2016).Compared to other groups, spousal caregivers often report high intensity in terms of hours of care and types of tasks (AARP and National Alliance for Caregiving, 2020; Pinquart & Sörensen, 2011;Wolff & Kasper, 2006).They also tend to have fewer resources, such as less informal support and poor health, than other groups (Pinquart & Sörensen, 2011), which make them more vulnerable to negative effects of caregiving mental health.A meta-analytic comparison revealed that caregiving spouses had more depressive symptoms and higher levels of psychological distress than other family caregivers (Pinquart & Sörensen, 2011).Given the vulnerability of caregiving spouses, identifying factors that exacerbate or are protective against poor mental health is important.

Resources and stressors for caregivers
The effect of caregiving on health and well-being varies depending on psychosocial resources.For instance, the negative effect of caregiving decreased significantly among caregivers with high levels of self-efficacy and social support (del-Pino-Casado et al., 2018;Hajek & König, 2016;Meyer et al., 2021).Family is the most common source of social support, but social relationships and resources also exist outside the family and the household, such as those among neighbors.Social cohesion, defined as the willingness of community members to help each other (Stanley, 2003), has been identified as a neighborhood factor influencing residents' health and well-being, including life satisfaction, positive affect, depression, and psychological distress (Choi & Matz-Costa, 2018;Cramm et al., 2013;Kim et al., 2020).Several studies also reported that neighborhood social cohesion buffered the effects of daily stressors on negative affect (Kingsbury et al., 2020;Robinette et al., 2013).This is because as a psychosocial resource, neighbors in cohesive neighborhoods can provide emotional and instrumental support.
Several studies have investigated the effect of neighborhood social cohesion on caregivers' well-being.Rote et al. (2019) examined an association between neighborhood cohesion and well-being among the Mexican-origin population and found that family caregivers who lived in more cohesive neighborhoods had fewer depressive symptoms compared to those who lived in less cohesive neighborhoods.In addition, Lee and Marier (2021) recently found that neighborhood social cohesion predicted fewer depressive symptoms among older couples residing in the community.They also found that neighborhood social cohesion buffered the negative effect of living with a spouse with dementia on depressive symptoms.Given that prior theory and empirical work suggest that emotional and instrumental supports in more socially cohesive neighborhoods may promote caregivers' mental health, we hypothesize that neighborhood social cohesion will be associated with fewer depressive symptoms among spousal caregivers of older adults.
Although neighborhoods can provide an additional layer of social support to residents, they can also be a source of stress.Neighborhood disorder, defined as "observed or perceived physical and social features of neighborhoods that may signal the breakdown of order and social control" (Gracia, 2014, p. 4325), is an established stressor that affects the health and well-being of residents.Numerous studies have found that neighborhood disorder is associated with anxiety, more depressive symptoms, and higher psychological distress (Cho, 2022;Hill & Maimon, 2013;Pai & Kim, 2017;Ross & Mirowsky, 2009).Experiencing multiple stressors may increase the adverse impact of caregiving on mental health.For instance, previous studies have reported that ongoing chronic stressors, such as caregivers' health problems and financial strains, increased caregiving stress and resulted in poor health outcomes (Kim et al., 2017;Liu et al., 2019;Meyer et al., 2021).The ecological model of the stress process (Aneshensel, 2010;Pearlin et al., 1981), which shows how stressful life events and strains affect mental health, also suggests potential joint impact of chronic life strains and the persistence of ambient neighborhood stressors.As a stressor, neighborhood disorder may also increase the adverse impact of caregiving on mental health.Thus, we also hypothesize that spousal caregivers of older adults who report more neighborhood disorder will also experience more depressive symptoms.
Despite the potentially important role of neighborhood disorder as a stressor that poses additional stress to caregivers, no study has explored the relationship between neighborhood disorder and caregivers' mental health.Moreover, there has been relatively little attention to the relationship between neighborhood social cohesion and caregiver mental health.Thus, our understanding of the importance of the neighborhood as either a source of support or stress remains limited.To fill the gap in our knowledge, this study aims to examine the association of perceived neighborhood social cohesion and neighborhood disorder with depressive symptoms among caregiving spouses in a national study of older adults.Findings of this study will deepen our understanding of the role of neighborhood factors as resources or stressors in caregivers' mental health and inform the development of a targeted intervention for caregivers at a greater risk of poor mental health.

Data and sample
This study used data from the Health and Retirement Study (HRS) (https://hrs.isr.umich.edu/about),which is a publicly available longitudinal panel study that surveys a nationally representative sample of Americans over the age of 50 and their spouses.Questions about respondents' evaluation of their neighborhoods were included in a self-administered Psychosocial and Lifestyle Questionnaire.A random half of the sample was selected to complete the questionnaire in 2006 and the other half was given the questionnaire in 2008 (Smith et al., 2017).
Our sample is composed of spousal caregivers.We defined a respondent as a caregiver if their spouses with at least one limitation in activities of daily living (ADL) or instrumental activities of daily living (IADL) identified the respondent as their primary caregiver (Kim et al., 2017;Meyer et al., 2022).For this study, we used six waves of the HRS (2006HRS ( -2016) ) and allowed respondents to be included in our sample if they were providing care during any of the waves.The 2006-2016 HRS includes 3,441 respondents aged 52 and older who lived with their spouses in the community and provided help with ADLs and/or IADLs to them.

Depressive symptoms
We used a summary measure of depressive symptoms assessed using the shortened Center for Epidemiologic Studies Depression scale (CES-D) (Santor & Coyne, 1997), which includes six negatively worded items (depression, everything is an effort, sleep is restless, felt alone, felt sad, and could not get going) and two positively worded items (felt happy and enjoyed life).
Respondents were asked whether they experience any of the above-mentioned sentiments for all or most of the time over the week prior to the interview.Responses to eight indicators (responses to positively worded items were reverse-coded) were summed (range: 0-8; Chronbach's α = .80),with higher values indicating more depressive symptoms.

Perceived neighborhood social cohesion
Perceived social cohesion was assessed using four items (Cagney et al., 2009) assessing how respondents felt about the area within a mile, or 20 min walk of their home.Respondents used a seven-point scale to indicate the degree to which they agree to the following statements, with higher scores indicating stronger agreement: I really feel part of this area.
Most people in this area can be trusted.
Most people in this area are friendly.
If you were in trouble, there are lots of people in this area who would help you.
Responses were averaged using row mean commend (range: 0-6; Chronbach's α = .86)with higher values indicating higher levels of neighborhood social cohesion.Those who have missing values on more than two items were set to missing (Smith et al., 2017).

Perceived neighborhood disorder
Perceived neighborhood disorder was measured using four items (Cagney et al., 2009).Respondents used a seven-point scale to indicate the degree to which they agree to the following statements: Vandalism and graffiti are a big problem in this area.
People would be afraid to walk alone in this area after dark.This area is always full of rubbish and litter.
There are many vacant or deserted houses or storefronts in this area.
Responses were averaged using row mean commend (range: 0-6; Chronbach's α = .80),with higher values indicating greater per- ceived neighborhood disorder.Those who have missing values on more than two items were set to missing (Smith et al., 2017).
Covariates.Models include sociodemographic covariates, household factors, and other potential confounding factors: age (in years), gender (male [reference group]; female), race/ethnicity (non-Hispanic white [reference group]; non-Hispanic black; non-Hispanic other; Hispanic), educational attainment (less than high school [HS] [reference group]; HS; more than HS), spouse relationship (not very close-very close), child living with or nearby (no [reference group]; yes), functional limitation (no [reference group]; yes), neuroticism, types of care (IADLs only [reference group]; ADLs only; both IADLs and ADLs) and hours of caregiving per day (range: 0-24).Neuroticism was included based on previous findings linking personality traits and depression (Sadeq & Molinari, 2018).For personality trait neuroticism, respondents were asked to describe how well the four items (moody, worrying, nervous, calm) describe them (not at all-a lot).Responses were summed (range: 0-3), with higher values indicating a more neurotic personality.

Analysis plan
We first presented sample characteristics.We then tested whether neighborhood characteristics (i.e., neighborhood social cohesion and disorder) were associated with depressive symptoms using negative binomial regression.Model 1 only included sociodemographic characteristics, household factors, and other potential confounding factors.In Model 2 and Model 3, neighborhood social cohesion and disorder were included separately and in Model 4, both variables were included.Since some respondents have multiple observations (maximum = 3), we report cluster-adjusted standard errors with model estimates.Sample weights provided by the HRS were applied in all analyses to account for the complex survey design and sample composition.Analyses were conducted using Stata 15.

Sample characteristics
Table 1 shows the description of the sample.The average CES-D score was 1.56 (SD = 2.01).The mean scores for neighborhood social cohesion and disorder were 4.36 (SD = 1.44) and 1.64 (SD = 1.45), respectively.The majority of the sample were female, non-Hispanic white, providing assistance with both IADLs and ADLs, without functional limitation, and have more than high school education and child living with or nearby.On average, the sample was providing care to their spouse for 4.08 (SD = 5.83) hours per day.

Multivariate analysis
Table 2 presents binomial regressions of spousal caregiver CES-D scores.Model 1 included sociodemographic characteristics, household factors, and other potential confounding factors.Being older and having close relationship with spouse were associated with lower CES-D scores, while being female, being non-Hispanic Black, being Hispanic, longer hours of caregiving, providing help with both ADLs and IADLs, and having functional limitations and neurotic personality were associated with higher CES-D scores.In Model 2, we examined the association of neighborhood social cohesion with depressive symptoms, controlling for sociodemographic characteristics, household factors, and potential confounding factors.Higher levels of neighborhood social cohesion were associated with fewer depressive symptoms (b = -0.06,95% CI: −0.10, −0.02, p < .01).In Model 3, we examine the association of neighborhood disorder with depressive symptoms adjusting for sociodemographic characteristics, household factors, and potential confounding factors.Higher neighborhood disorder was associated with higher CES-D scores (b = 0.04, 95% CI: 0.01, 0.08).In Model 4, we included both neighborhood social cohesion and disorder.Respondents who reported higher levels of neighborhood social cohesion continued to exhibit lower CES-D scores than those who lived in less cohesive neighborhoods (b = -0.06,95% CI: −0.12, 0.00).However, the association between neighborhood disorder and CES-D scores was reduced and no longer statistically significant (b = 0.01, 95% CI: −0.05, 0.06).

Sensitivity analysis
The results may be biased because one third of the sample was lost due to missing answers to at least one variable included in this study.To remove potential bias and confirm the findings, additional analyses were conducted using twenty complete data sets that were created using multiple imputation by chained equations.Overall, similar patterns were observed; both neighborhood social cohesion and neighborhood disorder were significantly associated with CES-D scores when included separately and the association between neighborhood disorder and CES-D scores disappeared while neighborhood social cohesion remained significant in the final model [see Supplementary Material: Sensitivity Analysis Table C].This study included skewed variables: neighborhood social cohesion (skewness = -0.94),neighborhood disorder (skewness = 0.89), and hours of caregiving (skewness = 2.25).To remove skewness and increase accuracy of the results, we estimated the models using transformed variables (i.e., squared neighborhood social cohesion [skewness = -0.26],square-rooted neighborhood disorder [skewness = -0.16],logged hours of caregiving [skewness = 0.91]) and the results using the transformed variables were similar to the results presented in this study [see Supplementary Material: Sensitivity Analysis Table D].
This study used subjective measures of neighborhoods.While prior research reported that mental health is more affected by subjective measures (e.g., Zhang et al., 2019), it is possible that objective measures influence caregivers' mental health differently.When we included objective neighborhood disorder in our model, the association between objective neighborhood disorder and CES-D scores was not statistically significant and the inclusion of objective neighborhood disorder did not change the association between neighborhood social cohesion and CES-D scores (results not presented), therefore, we did not include it in our final model.

Discussion
In this study, we examined whether the perception of disorder and social cohesion were related with depressive symptoms among spousal caregivers.This is among the very few studies to demonstrate the role of neighborhood social cohesion as a potential resource and disorder as a potential stressor in the context of caregiving.Neighborhood social cohesion was associated with lower CES-D scores among caregivers, which is consistent with previous studies that report neighborhood social cohesion as a protective factor for caregiver well-being (Lee & Marier, 2021;Rote et al., 2019).This may be because neighborhood social cohesion encourages caregivers' engagement in community, which can promote access to social networks and provide opportunities for social interactions (van den Berg et al., 2017).Social networks and interactions have been shown to provide caregivers with emotional support, information about supportive services, and help with completing daily tasks in times of need (Chang et al., 2001;Seifert & König, 2019), which contribute to lowering caregiving burden and stress (Chang et al., 2001;del-Pino-Casado et al., 2018;Tang et al., 2019).Neighborhood social cohesion or social ties and networks in neighborhoods also can reduce social isolation and loneliness (Kemperman et al., 2019;Yang & Moorman, 2021), which are prevalent in caregivers (Anderson & Thayer, 2018;Beeson, 2003;Victor et al., 2021) and lower their well-being (Beeson, 2003;Ekwall et al., 2005).
Perceived neighborhood disorder was significantly associated with more depressive symptoms as expected.The adverse effects of undesirable neighborhood features, including crime and physical disorder, on mental health have been reported in previous studies (Barnett et al., 2018;Choi & Matz-Costa, 2018;Pai & Kim, 2017).Perceived neighborhood disorder may engender greater feelings of fear of going out of the house.Indeed, previous studies reported that neighborhood disorder was associated with increased fears of victimization (Kruger et al., 2007;Lorenc et al., 2013;Ross & Jang, 2000;Scarborough et al., 2010).Through fear of victimization, neighborhood disorder can limit caregivers' opportunities and access to resources available in the neighborhood (Collins & Marrone, 2015;Hale, 1996).In a study conducted among Medicaid beneficiaries (Latham & Clarke, 2018), the presence of neighborhood physical disorder was associated with a lower likelihood of visiting family and friends and participating in clubs and organizations.The lack of access to supportive resources, including social support and services, often results in increased caregiver burden and higher risk for social isolation and depression (Bass et al., 1996;Chang et al., 2001;del-Pino-Casado et al., 2018;Gaugler et al., 2003).Several development plans shown to be effective in removing visible signs of disorder, such as graffiti, trash, and abandoned   or demolished houses and buildings, as well as crimes and violence in the neighborhoods.For instance, the City of Philadelphia enforced a Doors and Windows Ordinance that required property owners of abandoned buildings to install working doors and windows in 2011.After remediating abandoned buildings, total crimes and many forms of violence and nuisance crimes in the area decreased significantly (Kondo et al., 2015).
This study also found a potential protective effect of social cohesion that buffers the negative effect of neighborhood disorder.The protective effect of neighborhood social cohesion against the ill-effect of adverse neighborhood factors, including neighborhood disorder and unsafety, has been frequently reported in previous studies (e.g., Choi & Matz-Costa, 2018;Geis & Ross, 1998;Ross & Jang, 2000).This is because social ties and trust available in cohesive neighborhoods reduce fear of victimization (Scarborough et al., 2010) that neighborhood disorder causes (Kruger et al., 2007;Lorenc et al., 2013;Ross & Jang, 2000;Scarborough et al., 2010).Our findings suggest that spousal caregivers may be less influenced by neighborhood disorder when they feel that they can rely on their neighbors.Therefore, policies and programs aimed at promoting caregiver well-being should prioritize strengthening social ties in neighborhoods, especially in neighborhood with high disorder.Creating safe and accessible community centers and outdoor spaces and providing residents with opportunities for participation in neighborhood activities (e.g., volunteering, art and cultural activities) may increase positive relationships and neighborhood social cohesion (Breedvelt et al., 2022;Jennings & Bamkole, 2019).

Limitations
First, we identified caregivers and hours of caregiving based on reports by the care recipients as a proxy.Therefore, it is possible that the spousal caregivers in this study would not identify themselves as caregivers.Furthermore, there is a potential discrepancy between hours of caregiving reported by care recipients and the actual hours that the spousal caregivers provided assistant to the care recipients.Second, our sample only includes spousal caregivers of older adults who have ADLs or IADLs.Therefore, the findings of this study may not be applicable for caregivers of those who have illness, but without ADLs and IADLs.In addition, this study focused on spousal caregivers, the findings of this study may not be applicable for other types of caregivers (e.g., children, friends).Lastly, this study used a cross-sectional design, which limits our ability to assess the directionality of the relationship between perceived neighborhood characteristics and depressive symptoms of spousal caregivers.For instance, more depressed caregivers may perceive less social cohesion or more disorder.Future studies are needed to explore the causal relationship between neighborhood characteristics and mental health among spousal caregivers.

Conclusion
Our study highlights the importance of neighborhood contexts in understanding caregivers' well-being.Findings of this study suggest that neighborhood stressors lower caregivers' well-being, but supportiveness of environments likely matters more.Policymakers and practitioners should focus on enhancing positive characteristics of the neighborhood and supporting social ties in neighborhoods, which can promote mental health of spousal caregivers.Further investigation to explore the effect of diverse aspects of neighborhoods (e.g., availability of supportive services and amenities) on caregivers' mental health and to clarify psychosocial processes linking neighborhood characteristics and caregiver well-being would contribute to caregiving literature and inform policy and intervention strategies.